Kiwiblog

It is inevitable that a future Labour Government will include the Greens, as they no longer have Jim or Winston to rely on. So with that in mind, let us look at what the Greens say their health priorities are:

1. In retrospect I have to confess that our decision to fund 12 months’ treatment with Herceptin was sheer irrational populism, and today I’m announcing that we will never do it again. In the same spirit, our repeal of the healthy school food guidelines and cutting funding to Healthy Eating Healthy Action projects were entirely about ideology rather than health, so we’re reintroducing them because we are quite concerned about chronic illness.

So their number one health priority is to provide a shorter period of treatment to women with breast cancer. I can’t wait for No 2.

2. Rather than making the grand gesture of a massive programme to build new operating theatres and contracting out surgery to the private sector, Government has today announced a programme of regionally (rather than locally) planning the best and most efficient use of our existing theatres, specialists and resources.

And their number two health priority is to have fewer operating theatres. This just gets better and better. Vote Green and we promise less treatment for women with breast cancer and fewer operating theatres.

3. I think we’ve had enough of committees, reports and endless restructuring, so rather than commission yet more I am going to require DHBs to work together and help each other whenever this is in the interests of most New Zealanders.

Their third health priority is that they are going to send a memo out to DHBs telling them to work together better.  Such vision.

4. It is inadequate and unacceptable for us to set lower health targets for Maori and to continue to tolerate health inequalities. The performance measures I am setting for DHBs will focus on raising Maori health status to the same level other New Zealanders enjoy, and DHBs will perform to this standard (or they’re all fired!)

This one is so crazy, it has me laughing. The Greens are going to sack every District Health Board in New Zealand unless they can get Maori health status to the same level as non-Maori. Are they going to supply pixie dust to help them do the job?

It is an interesting insight into the mind of those on the hard left. They really believe that the reasons for the disparity between Maori and European has nothing to do with culture, genetics, environment, family and personal decisions – but is all the fault of the DHBs, who will be sacked if they can’t fix it.

5. In order to improve the position of those people with the poorest health, Government will be requiring all Government departments and crown entities to work together at a local level to identify people in need and to proactively offer services to improve their lives, and will be funding PHOs to take a lead role in this process.

So number five health priority is to send out a memo to Government Departments asking them to work better at helping people with poor health.

6. There is not enough money now to provide all of the health services that New Zealanders expect, and this will be worse in the future. Consequently Government is reorienting our health sector spending to focus resources in the areas proven to have the greatest impact on population health status, public health programmes and primary care, and as Minister I will also personally lead a national conversation with New Zealanders about how we best make decisions about how we should allocate limited resources in secondary and tertiary care.

And their final health priority is to have a conversation about umm health priorities, with an eye towards reducing secondary and tertiary care.

So in summary these are the Green’s six priorities for health:

1. Reduce the amount of treatment for women with breast cancer
2. Reduce the number of operating theatres
3. Send out a memo to DHBs saying work better together
4. Sack every DHB in New Zealand if they can not magically bring Maori health status up to the level of non-Maori
5. Send out a memo to Government Departments to say be nicer to people with poor health
6. Try and convince NZers to have less money spent on surgery and hospitals.

Oh I am looking forward to a future Labour/Green Government. It will be such fun.

The NZ Herald looks at the TVNZ decision to bump John Key for Robin Brooke:

It is reassuring, in its way, that the Prime Minister could not commandeer the airwaves on state television on Tuesday to tell the nation about income tax cuts and a rise in GST. It speaks of TVNZ independence and editorial freedoms that should be valued, however questionable the actual judgment of those exercising them.

The Herald also looks at the drug law reform paper:

Mr Power’s problem with the Law Commission recommendations seems to stem from from the Prime Minister’s declared war on methamphetamine and drugs. Any relaxation would be perceived as contrary to that. It could also be argued, as John Key did yesterday, that softening the law on the possession of drugs for personal use would send the wrong message to youngsters. …

Given such political reality, there was a strong whiff of naivety in the commission’s suggestions. There was also, however, a solid strain of reason and rationality.

The commission, for example, is right to note that “while the harms and costs associated with alcohol are understated and misunderstood, those associated with illegal drugs are often generalised and overblown”. There is also much to say that drug policy should focus on dealing with problematic drug-users, rather than the many people whose drug use poses no serious threat to their own well-being or others.

I agree. that the focus should be on those drug use creates problems, rather than those who do not.

The Dominion Post talks about PHOs:

On paper, the last government’s decision to establish primary health organisations had a lot going for it. Bringing together doctors, nurses, midwives and other health professionals under one roof was a way to improve access to services and reduce overall health costs by reducing the need for hospital admissions.

In practice, as invariably happens when a government opens its cheque book, the results have been mixed.

A study by Capital and Coast District Health Board last year showed avoidable hospital admissions in the district have increased since 2003, but have fallen among people enrolled with PHOs. PHOs are also credited with increasing immunisation rates in some parts of the country and making visits to doctors more affordable for people in poor areas, although the latter is more likely to be a consequence of increased subsidies than the way the sector is organised.

However, some PHOs barely exist except on paper (their purpose is to channel money from district health boards to individual clinics) and their creation has contributed to a rise in administration costs.

Not exactly a stunning success.

The Press talks about Environment Canterbury:

For the second year in a row Environment Canterbury (ECan) is heading towards an overall rate increase well in excess of inflation.

Last year it approved a rise of 6 per cent, including a 10.6 per cent general rate rise, but if that decision prompted disquiet in the region, the questioning of ECan could well be even stronger this year. …

With the local body elections looming later this year, ECan ratepayers will be closely watching over coming months to see which councillors are prepared to identify areas where savings could be found, especially in the regional council’s bureaucracy.

We should have candidates sign pledges that they will not increase rates beyond inflation without voter approval.

The ODT looks at the merger of the Otago and Southland District Health Boards:

The way is cleared for the merger between the Southland and Otago District Health Boards with the Southland board’s 7 to 3 vote in favour.

Because Health Minister Tony Ryall is likely to back the proposal, the only remaining major issue is the speed of approval and whether the Southern Board will be in place early enough for this year’s local body elections in October. …

I suspect it will be.

The Herald reports:

Primary health services are about to undergo their biggest shake-up in nearly a decade, shifting some hospital services into the community and creating new super-clinics.

The kinds of services the integrated family health centres might offer are expected to include minor skin surgery, referral to diagnostic imaging and consultations with hospital specialists. …

The Health Ministry has provisionally accepted nine bids from groups of PHOs and DHBs for devolution of some hospital services to primary care – they must remain free to patients – and the creation of integrated family health centres.

It all seems sensible, so I wonder why it hasn’t happened earlier.

Services provided by integrated family health centres could include:

* 24-hour accident and medical care.
* Laboratory collection, some on-site testing.
* Clinical psychology, counselling.
* Dental care.
* Midwifery clinics.
* Acute assessment and observation beds.
* Minor surgery.
* Consultations with specialists.
* Referral for magnetic resonance imaging.

It will be interesting to see one in operation.

John Armstrong writes:

It is not that long ago – only a matter of months – that the loss of 500 jobs in a crucial branch of the state sector would have been the major news story of the day. …

The same could not be said about this week’s announcement that the axe will fall on close to 500 positions in the Ministry of Health and across the country’s 21 district health boards over the next 18 months.

The media reaction was very ho-hum despite the layoffs actually being closer to 700 once 200 vacant positions in the Ministry of Health which will not be filled were included in the tally. …

Increasingly, the feeling is that the public has – to borrow from Helen Clark – moved on from the days when it could get outraged by the merest hint of slash-and-burn spending cuts or privatisation. The assumption was that National won last year’s election through John Key positioning his party more to the centre. It is clear now that a large portion of the electorate had already shifted to the right.

John is partly right here, but only partly. The public mood has shifted, but I would not call it a shift to the right. It is the same shift we have seen in the UK, where most of the public now support spending cuts.

It is not a change in political views, but a reaction to the recession. Part of it is a feeling of shared belt-tightening. If businesses and households can tighten their belts, so can the Government. And it is partly that people do understand huge deficits and massive borrowing is not sustainable.

The other aspect I would point out is that it is hard to call what Ryall is doing as slash and burn spending cuts. He has promised that Vote Health will not decrease, but the gains from the bureaucracy reduction will be transferred into frontline services. This changes things considerably.

Well almost the entire health sector seem to be united behind the changes announced by Tony Ryall. This degree of unanimity is very rare. In fact I think the last time it happened was in the early 90s when the Young Nats proposed selling off all 23 CHEs to the private sector (on the basis of there being a funder/provider split, and ownership of providers did not matter), and we got condemned by every health group and political party there was – including National’s own Minister and Under-Secretary

Getting widespread support in favour, rather than against, what you are doing is harder but here is reaction yesterday:

NZMA:

The New Zealand Medical Association (NZMA) today welcomed the announcement by the Government of substantial changes to the health system.

“It makes great sense to rationalise the backroom services of the District Health Boards (DHBs) and to provide much greater coordination of national services and we support the decision to place the National Health Board within the Ministry of Health,” said NZMA Chair Dr Peter Foley.

NZNO:

The New Zealand Nurses Organisation (NZNO) supports announcements made today by the Minister of Health, Hon Tony Ryall, which will see greater collaboration in health across New Zealand’s 21 District Health Boards (DHBs).

“We are pleased that the Government and the Minister have taken heed of the submissions made in response to the Ministerial Review Group report ‘Meeting the Challenge’. We welcome any additional resources to workers at the front line of the health service,” said NZNO President Nano Tunnicliff.

“The changes signalled are a sensible continuation towards a more nationally integrated health service,” Tunnicliff said.

ASMS:

“We are chuffed that the government has listened to advice from us and others on the health proposed by the Ministerial Review Group (Horn Report),” said Mr Ian Powell, Executive Director of the Association of Salaried Medical Specialists, today.

“The Horn Report recommended creating a new bureaucracy, the National Health Board, as a separate, less accountable crown entity, in addition to the Ministry of Health. This would have involved major restructuring, and risked increasing bureaucratic wastage and generating paralysis in decision-making. We supported the functions proposed for the National Health Board but not the recommended structure.”

“We have worked hard lobbying government not to go down this path. Instead we recommended that the functions be allocated to a specific enhanced unit within the Ministry of Health. This is exactly what Health Minister has announced today and we are delighted. It is a relatively novel experience of a government listening to us in such a specific way.

And even the Health Cuts Hurt lobby group:

“Health Cuts Hurt supports the principles behind the Government’s decisions about the public health system announced today but is concerned that the devil is in the so far undelivered detail,”

“How can you oppose more consolidation of the administrative functions like purchasing in bulk and more regional cooperation in service delivery along with returning savings from these things into more operations or hospital beds,” said Heather Carter.

Oh I am sure Labour can, if they try hard enough

HFANZ:

Efficiency gains expected as a result of changes to the public health system announced by the Government today have been welcomed by the Health Funds Association (HFANZ).

Tony Ryall really is doing well with what is traditionally a very dangerous portfolio. If only, the same could be said across the entire Government!

Tony Ryall has announced:

“Cabinet has agreed to a number of proposals from the Ministerial Review Group’s report ‘Meeting the Challenge’ that will greatly improve national and regional cooperation and reduce duplication of back office functions, ” the Minister said.

As a package, the changes will move up to an estimated $700 million in savings over five years to frontline services. That would buy about 16,000 heart bypass operations or build two large city hospitals.  The changes are also expected to reduce the health system bureaucracy by up to 500 administration jobs. These would be managed as much as possible through attrition and voluntary redundancy. …

The major changes include setting up a new National Health Board (NHB) within the Ministry of Health. The NHB will focus on supervising the $9.7 billion of public health funding the 21 DHBs spend on hospitals and primary health care.

The new NHB will manage national planning and funding of all IT, workforce planning and capital investment. It will also take national responsibility for vulnerable health services such as paediatric oncology.

Work will also start on consolidating the 21 DHBs’ back office administrative functions such as payroll and bill payments.

“Officials estimate a one-off cost of between $5 and $10 million to set up the changes and that will be met within the Vote Health budget. Up to an estimated $700 million is expected to be saved in the first five years from coordinating procurement and logistics. All savings will be reinvested back into frontline health services.”

I don’t think anyone can object to the intention of these changes. If they save even a fraction of what the official cite, that will be a good thing freeing up money for frontline services.

The challenge for the Government is to have them go smoothly. INCIS is a prime example of good intentions going astray.

But I’m pleased the Government is prepared to take the risk, in order to make improvements. The status quo is not good enough.

MacDoctor nails it here:

If you were wondering why Labour spent so much extra money on Health without actually improving the health of New Zealanders, nor their access to services, puzzle no longer. Ruth Dyson reveals all. She is complaining that some of the health promotions that were dear to Labour’s heart have been cut or seriously curtained. Things like cancer “control”, heart promotions and the diabetes “get checked” programme. …

No, Ruth, these are NOT frontline services. They never were and they never will be. These are all Labour’s attempts at preventative health promotion and, as such, provide no health service at all. This is not to say that preventative health is necessarily useless, just that they are not frontline services. They are not delivering medicine, they are delivering social change. At least, they might be delivering this.

That is a great line – they are not delivering medicine, they are delivering social change.

That does not mean all public health activies are not worthwhile, but they are not the same thing as actually giving someone an operation, a prescription etc.

The biggest problem with all of these preventative health schemes is that no one appears to have bothered to examine whether they are making any difference. Labour’s attempt to monitor results of these campaigns (now removed from the health reporting list by National) were so wishy-washy and soft, that it was impossible to tell from the data whether they were successful. That does not seem like a good use of taxpayer dollars to me.

Take the diabetes programme “get checked”, for example. This programme, unlike most, actually has links to hard data like blood results, blood pressure readings and hospital admission rates for diabetes and diabetic complications. All the hard evidence shows that the programme has made virtually no difference to the quality of diabetic control.

Huge amounts have been spent on programmes that *might* improve health outcomes. But what data there is, is patchy.

Diabetics who normally don’t attend their regular check-ups don’t abscond because they can’t afford it, they don’t come in because they can’t be bothered. Diabetes is one of those diseases that kill you slowly, like high blood pressure (only worse). People don’t like to see the doctor unless they are sick. So they don’t. All that “get checked” does is make it cheaper for the people who would have regularly attended their doctors for diabetic monitoring. It is a subsidy for diabetics. Nothing more, nothing less.

More middle class welfare.

There is nothing wrong with this. It is just not something you want to fund at the expense of real frontline services like outpatient visits and elective surgery.

Which is what Tony Ryall is sensibly targeting.

Labour’s singular failure in health is their constant focus on what would be nice at the expense of focussing on what is truly needed.

Dead on target here.

Nobody is saying that heart prevention programmes are invariably a waste of time. We may demonstrate that they may be very useful indeed at reducing long-term heart disease. But it is not right that a dozen people should die because they can’t get heart surgery in time in order to fund a social intervention. Particularly one that does not have demonstrable benefits.

This is how Labour managed to double health spending but almost make no impact on waiting lists etc.

Tony Ryall announced yesterday $104 million over four years for additional maternity funding:

• Longer stays for new mothers in birthing facilities
• An optional meeting each trimester for at risk mothers, attended by the pregnant woman, their GP, and their lead maternity carer (usually a midwife)
• Obstetric training or refreshers for GPs wishing to return to maternity care
• Fully funding the Plunketline 24 hour telephone advice service

I think the second point may be the most important. The changes made in the late 1980s by then Health Minister Helen Clark have been a disaster for many parents. GPs have abandoned maternity services, and doctors and midwives have often been silos – not talking to each other.

And far far too many babies have died needlessly, because of a lack of competence amongst some (not all) midwives. A refusal to call in a specialist has proven fatal too often.

So the three monthly meetings between mother, GP and leader carer is a commendable initiative.

The NZ Herald editorial favours the new health targets:

Targets can be the bane of any organisation. Unless they are well defined and readily measurable they are worse than useless, create more work than necessary and waste time and money that could be used for something more useful. The Minister of Health, Tony Ryall, has found some classics among the previous Government’s targets for district health boards (DHBs), which he has culled from 10 to six.

Worse than that:

As he put it, “We have inherited a system overburdened with 13 health priorities; 61 objectives, with an additional subset of 13 health objectives; a set of 10 health targets measured through 18 indicators; 25 other indicators of DHB performance; not to mention four hospital benchmark indicators assessed through 15 measures; and an outcomes framework with nine outcomes measured against 39 headline indicators”.

And think of all the administrators needed both at DHB level, but also at the MOH to measure and report on all these.

When Labour scrapped the previous National Government’s business model for hospitals and related services, replacing Crown health enterprises with district health boards, it made much of the democratic element of elected boards. But in fact the boards were set up as branch offices of the Health Ministry, which decided most of what they would do.

Having elected members on DHBs, actually dilutes accountability as it allows the Minister to blame the local DHB and vice-versa.

This Government is content to keep Labour’s administrative structure and the best it can do is try to simplify its procedures. Impractical, largely symbolic declarations on nutrition, obesity and physical activity have gone. As Mr Ryall said, how could a district health board be held responsible for increasing the number of people who ate the recommended daily portions of fruit and vegetables?

The six goals he has set look sharper: shorter stays in emergency departments (95 per cent of patients to be admitted, discharged or transferred within six hours), faster elective surgery (an increase of 4000 a year), shorter waits for cancer treatment (radiation within six weeks by August next year, and four weeks by December).

Those three are treatment targets, the rest are preventive: immunisation for 85 per cent of 2-year-olds by July next year, rising to 95 per cent two years later; help for hospitalised smokers to stop; more people to be assessed for risk of heart disease and more free checks for people with diabetes.

Inevitably, there will be complaints that worthy causes have been ignored. Already the Obesity Action Coalition asks where responsibility for nutrition, physical activity and obesity lies if not with health boards. Well, many could answer that one. It lies with the individual.

You can’t trust individuals – once you start doing that, society will crumble.

The ODT reports that Tony Ryall has set just six targets for DHBs (I presume on top of don’t run out of money). They are:

1. cut emergency department waiting times so 95% treated within six hours
2. deliver faster treatment for cancer patients – all those needing radiation treatment to get it within six weeks by July 2010 and within four weeks by Dec 2010
3. carry out more elective surgery – an extra 4,000 operations per year
4. more immunisations – 85% immunised by July 2010, 90% July 2011 and 95% July 2012
5. better help fro smokers to quit – 95% of smokers in hospital to be given advice and help to quit
6. better diabetes services

What were the targets from the previous Government:

1. 13 health priorities
2. 61 objectives
3. additional subset of 13 health objectives
4. 10 health targets measured through 18 indicators
5. 25 other indicators of DHB performance
6. 4 hospital benchmark indicators assessed through 15 measures
7. an outcomes framework with 9 outcomes, measured against 39 headline indicators

Sounds like doctors may have more time to see patients and be spending less time reporting on priorities, objectives, indicators and outcomes. Also sounds like we may have a few less administrators.

I saw in the Herald that a Tim Dare has responded to the excellent op ed by Dr Shaun Holt on the bureaucratic PC ethics approval system for the most basic of health experiments (the example was honey on a rash).

Now when Dr Holt did his original op ed I noted he provided an actual example of how the system was nonsense, and that he spoke from first hand knowledge, being a Doctor.

So before I even read Tim Dare’s response, I crolled down to the end to find out whether he was someone with a vested interest in defending the status quo. And indeed:

Dr Tim Dare is head of the department of philosophy at the University of Auckland and chairman of the Health Research Council ethics committee.

Interesting. Dr Dare is chairman of the HRC ethics committee (which makes him the ultimate vested interest) but he is also (to quote Rob Muldoon) one of those doctors who makes you sick, not well

But what does he say:

Dr Holt is moved in part by his experience as a former ethics committee member and researcher. He recently sought approval for a study looking at whether honey helped treat a common childhood skin condition.

“Only 15 children were required,” he reports, “and all the caregivers had to do was to apply the honey, cover with a dressing and see if it seemed to help.”

The ethics committee refused permission, he says, raising more than 40 objections. He gives as an example of its obstructive approach a requirement for Maori consultation.

This is misleading. I was a member and chair of New Zealand’s busiest health research ethics committee for seven years. Some very difficult applications, such as those requiring the development of new policy, took a long time. But the vast majority were dealt with at the meeting following their receipt (within two or three weeks), as required by national guidelines. Even allowing time for letters following that meeting, few were still open six to eight weeks after receipt.

He says this is misleading, but nowhere does he dispute that Dr Holt was refused permission and had over 40 objections to overcome to what appears to be the most simple of experiments.

And rather than quote actual statistics on turn-around, we only get told ” the vast majority” and “few”. I prefer hard numbers. But the issue is not just about time to make a decision, but the hurdles that applicants have to jump through prior to application.

Delays beyond that were often because researchers took time responding to committee requests for clarification or amendment.

So it is their fault. Again no statistics on this.

Dr Dare turns to Dr Holt’s proposal and comments:

Dr Holt’s account of the treatment of his own proposal is also less than complete. Ethics committee minutes are publicly available. The minutes for Dr Holt’s study before the Auckland committee (to see them, run NTX/08/09/085 through Google) indicate that the committee deferred a decision on Dr Holt’s honey project because they were concerned about its validity.

They seem concerned the study did not have enough participants and that parents were required to change dressings and wash the affected area during the study without an indication how Dr Holt would know whether it was the honey or the washing that made the difference. There is mention of Maori consultation, but it is not given as the primary reason for deferral.

These are very ordinary concerns about research validity: one of the legitimate roles of an ethics committee is to ensure that health therapies cannot claim to have been shown effective unless the research is rigorous and sound.

Note that the committee did not decline approval: they deferred a decision. Dr Holt chose to not clarify or amend his study.

It was good of Dr Dare to provide the Google reference as it does provide the minutes of the meeting. But I think the minutes prove Dr Holt’s point. Look at the changes that were demanded for such a simple study:

• Study, as it stands, is a pilot and this needs to be stated in the title, and then reflected in the design, the research question(s) and the PIS and consent form. Alternatively, the researcher may choose to power the study, after consulting a statistician
• Guidelines NAFG to be consulted.
• Part 1: Provide positions/qualifications/organisations of co-investigators
• A3.1: Insert information regarding washing the MC lesion every 2 days (same as PIS).
• A1.2: Explain what type of honey will be used and the justification for using this.
• A3: Study Design: It is planned to dress 1 MC with honey, cover it then, for the next four weeks, wash it every 2 days wash it, dress it with honey and cover it while the other MC is left untouched. Clarify how the researcher will determine which of these interventions is causing any effect seen.
• A3: Randomize over two chosen sites, and include an osmolarity control.
• A3: Explain how participant compliance with study design will be monitored between visits
• A4.1: Explain how the 15 child participants will be assigned in respect of each locality
• B10: Grounds for exclusion to be ‘factual’ not left to doctor.
• B11: Provide worksheet. What information is being collected and why?
• B12: Explain why a dressing known to cause allergic reactions will be used, rather than a non-adhesive dressing, and explain how the cause of any adverse reaction will be ascertained.
• B12: If removed from the study what treatment will be offered to the child?
• B16: Clarify ‘safety reasons’.
• D5/6/7: Data to be kept until age of majority plus 10 years (Health Act – Children)
• E: Researcher to explain how interpreters are accessed, if used
• Section F: Consultation needed from Tauranga Maori Health Providers. Honey is food – are there cultural implications?
• Locality Assessment Cannot be signed by PI. To be redone.
• Pt 4 Declaration: 2: Cannot be signed by PI. To be redone.
• B11: Provide worksheet?
• Provide an information sheet/consent form for children under 15.
• A8.1: Provide itemised budget that justifies the $900 payment to doctors. Without such detail we are unable to assess whether the payment to doctors might act as inappropriate inducement to recruit and retain.
• D4: The committee is concerned that having the initial approach made by the GP increases the potential for conflict of interest and coercion of the participant, given the payment per participant that is proposed.

Hell I would have given up at this point also.

An article full of revelations appeared on Monday by Shaun Holt on medical ethics in NZ. He explains:

As an experienced medical researcher and an ex-member of an ethics committee, I am likely to know about the ethical requirements of medical research. Last year I submitted an application for a simple study to see if honey could help treat a common skin infection in children that is otherwise very difficult to treat. Only 15 children were required for the study, and all the caregivers had to do was to apply the honey, cover with a dressing and see if it seemed to help.

Sounds about as simple as you can get. It is 1,000 miles away from let’s not treat this women for cervical cancer so we can see how effective the treatment is.

In order to apply to the ethics committee, I had to consult a Maori health provider to make sure there were no cultural issues if any Maori children took part and see a justice of the peace to sign a statutory declaration.

The application itself needed around 9000 words to complete and over 350 pages had to be submitted. For a study which could not be any simpler and had almost no chance of causing any harm, the application process took longer than doing the study would have.

This is the first stage of distress. Consulting a Maori health provider should not be mandatory – common sense should apply. And God forbid how you need 350 pages for such a simple study. Think of not only the cost to the healthcare system, but also the research that never happens due to such bureaucracy.

The study was rejected by the committee and around 40 points were raised, most of which were either wrong or not relevant to the ethics of the study. For example, I was told to consult at least two more Maori health providers and to have systems in place for interpreters, even though the study was to be undertaken by a few GPs who would ask their own patients with this condition if they wanted to take part.

Almost enough to make you weep.

It is no surprise he writes:

Medical researchers are hugely frustrated by the quality of the ethical reviews of their proposals, the work required for an application and the time taken for the responses and approvals. One of our leading orthopaedic surgeons has said the greatest impediment to medical research here is the growth of the ethics committee process.

We owe Dr Holt our thanks for speaking up. Hopefully the powers that be  will take note.

Hat Tip: MacDoctor

Phil Goff is upset that Tony Ryall may have caused a $350,000 primary health conference to be cancelled.

I think Mr Goff should keep campaigning in defence of taxpayer funded conferences.

Inaugural Health & DIsability Commissioner Robyn Stent writes in the Herald that then Health Minister Annette King changed the law in 2004 to allow the storage of body parts or bodily substances without the consent of the patient they came from, if it is for the purpose of approved research.

I’m all in favour of embryo research, but only if the parents give consent. It is shameful that Annette King nationalised their embryos to allow embryos to be stored without parental consent.

Poneke is in Brisbane and has discovered it has the buzz of prosperity:

On the surface, the prosperity can be seen in the world-class infrastructure of roads and electric rail lines that Auckland in particular has not been able to achieve despite decades of talk; the very high standard of housing, commercial buildings and public facilities; the wages that really are stunningly higher than at home; the many job vacancies in the papers even on the Saturday after Boxing Day. Australia has not had a single quarter of negative growth this year while we have had three (though the Aussies fret about it and fear recession might still happen). I could go on.

MacDoctor shares some first hand experience of emergency clinics:

An article in the Weekend Herald (not yet online) entitled “High cost stopping Kiwis visiting the doctor” tells us that over two thirds of New Zealanders over 20 have avoided visiting a doctor because of the cost. I didn’t need any research to tell me this is true, because these people pitch up to emergency departments throughout the country with the line, “I couldn’t afford to go to my GP”  or it’s alternative “I owe my GP too much money”. …

I view these two excuses with a great deal of cynicism. Many who use these lines are drunk or have nicotine stains on their fingers (or both). They drive up in expensive cars and sport MP3 players (many are genuine iPods). They typically arrive not long after the GPs have all closed for the evening, or over the weekend. These are the “milkers of the system”  - They know how to work the health system to their advantage and they use Emergency Departments like a GP clinic. …

I suspect most of the two thirds of New Zealanders who said that they do not go to a doctor because of cost, are really saying that they would rather spend their time and money on something other than their health. It has nothing to to with lack of access and much to do with lack of interest. Until we, as a society, start to see that health is important and worthy of investment, this problem will not go away, regardless of the amount of money governments may throw at it.

Hear hear. I think all bar the very poorest should pay something towards their healthcare.

Bernard Hickey recommends a Kim Hill interview with JJ Joseph – a man who used to beat his wife. It’s a very moving interview that shows people can turn their lives about.

And finally Lynn Prentice at The Standard manages to link Bernie Madoff’s ponzi scheme to National’s planned repeal of the EFA. The hilarious part is:

based on recent experience of their autocratic, arrogant, and undemocratic behavior in the house, we will probably see some opaque, badly written, and badly thought through legislation pushed through under urgency.

What does he call the EFA if not badly written and badly thought through? And he ignores of course that unlike Labour, National has said it will consult all parties over the replacement legislation. It was Labour that tried to use bipartisan electoral law to screw over its enemies.

From Monday’s Dom Post:

Just 67.5 per cent of category 2 patients including those suffering serious head injury, moderately severe trauma and suspected heart attacks were treated within the recommended 10 minutes.

Fewer than half of patients categorised as triage 3 those with fractures, breathlessness, bleeding or other conditions requiring urgent treatment but not considered life-threatening were seen within the recommended time of 30 minutes.

This result was “the worst performance bar one since they started recording data in 2001″, Mr Ryall said.

During their nine years in office Labour increased health spending from $6.1b to $11.6b. That is an extra $5.5 billion, yet still barely half of emergency patients get seen within recommended times.

Idiot/Savant is sceptical of the planned policy to have maximum waiting times for A&E. He claims that in the UK, the response to such targets was:

The policy is based on UK Labour’s attempts to improve quality in the NHS by introducing these sorts of absurd targets, and Ryall claims that policy was a success, having led to a reduction in the number of patients waiting for than four hours from 23% to 3%. But that success was an illusion. As noted in Adam Curtis’ documentary, The Trap, faced with pressure to improve their statistics, NHS managers created a new and unofficial post, the “Hello Nurse”, whose sole purpose was to greet new arrivals to A&E so they could claim for statistical purposes that the patient had been “seen”. Faced with a similar target aimed at reducing the number of patients waiting on trolleys in corridors, they simply removed the wheels from the trolleys and reclassified them as beds.

I’m not sure whether to be appalled or impressed by the ingenuity – reclassifying trolleys as beds!

The targets were met, but the underlying performance didn’t change one iota. Mangers being managers the world over, the same is likely to happen here. It’s a general problem with this sort of empty managerialism and obsession with statistical targets: the statistical goal – measured patient “waiting time” – ends up taking the place of the real goal – patient care. And doctors and nurses end up spending all their time filling in performance spreadsheets rather than doing what they’re supposed to be doing: seeing patients.

Idiot/Savant arguments would be stronger, if the status quo had not failed so badly. Under Labour we have had $3.5 billion of exra funding for health, no targets for A&E, and the result has been 20% of people waiting for more than eight hours.

Why does he think throwing more money at it, without targets will work? Can he cite an example in the world where it does?

As I said yesterday, the benefits of targets are it creates transparency. DHBs can cost what the cost will be to meet the six hour target. Dedicated funding can be applied for. If the Government refuses, then people can hold the Government accountable.

Rather than clinging to the dead 80’s cult of managerialism, National should target the real problem: lack of resources. The reason people have to wait so long in A&E is because hospitals cannot afford to employ enough medical professionals to deal with demand.

And without a target to aim for, how on earth can one calculate what it would costs to have the extra staff?

The reason they are parked on trolleys in hospital corridors is because there is not enough space. But solving these problems would cost money, which National would rather give to the rich in tax cuts. It’s just a question of priorities – and National clearly rates redistributing wealth to those who need it least well ahead of ensuring that every kiwi has decent access to healthcare.

And now we just get the blind slogans, instead of intelligent analysis. Idiot/Savant is not stupid. He has read National’s fiscal package. He knews that the tax cuts are being funded almost entirely out of changes to KiwiSaver. Not from less spending on Health.

In fact National has pledged significant funding to train up more doctors, to set up 20 new surgicial wards etc etc.

The Herald editorial is supportive of the policy:

It is also all the more reason to welcome Health Minister Tony Ryall’s plan to impose maximum patient waiting times on emergency departments, and to hold district health boards and their management accountable for meeting them. His initiative is sure to attract criticism. Such targets are always something of a crude measure, if only because they fail to give sufficient recognition to quality of care, which should, ideally, be hospitals’ paramount concern.

The target are no silver bullet, but frankly we should be debating why we have never had them before, not be surprised that these minimum measures of accountability are being introduced.

But Mr Ryall can be excused for starting at this point. There is a sense that, while the Labour Government increased the health budget by more than $3.5 billion, too much of this was swallowed with little discernible increase in efficiency. There were neither quantitative nor qualitative improvements. At the very least, targets incorporated into performance agreements will lay the foundation for better results by increasing accountability in emergency department operations.

Indeed. The status quo has seen massive funding and little way to judge how well utilised that funding was. Now that is great if you are Minister of Health, but not good for patients and taxpayers. This si why I said Ryall’s policy was brave – it actually creates an accountability for him as as Minister that was previously lacking.

The Herald reports:

Health Minister Tony Ryall will impose maximum patient waiting times on hospital emergency departments. …

The Herald reported yesterday that a consensus is emerging – in talks among senior physicians and health officials – that the maximum time should be six hours and that no patient should be left waiting in an emergency department corridor. Recommendations are expected to be made to Mr Ryall within weeks.

This is a very brave move by Tony Ryall. Under Labour we saw billions thrown into health, but very little measurable improvements for that money. This means that Labour could talk about how much it cared, but never be measured on success.

Tony is putting in place measures that will introduce better accountability. DHBs will have to front up and specify what resources they need to ensure they can see all A&E patients within six hours. The DHBs can be held to account for that, and also the Minister and central Government an be held accountable if they fail to adequately fund the DHBs.

He cited Britain’s success in reducing emergency department waiting times through a target maximum wait, set in 2004, of no more than four hours from arrival to admission, transfer or discharge. Within several years, he said, the proportion of patients waiting in emergency departments for more than four hours fell from 23 per cent, to 3 per cent.

In New Zealand, Health Ministry data from one large emergency department and two of medium size indicated that while the majority of patients were seen within several hours, up to 20 per cent at one of the hospitals spent more than eight hours in the emergency department.

Looks to be a good plan.

The final legacy of Labour’s healthcare policy. The Capital and Coast District Health Board has a $70 million budget blowout (funny how the Minister has not sacked them even though he sacked the Hawke’s Bay one for a far far smaller sum).

The DHB has said if it does not get bailed out, it may be unable to pay staff wages. I can’t imagine staff will work without getting paid somehow.

MacDoctor blogs on how Labour is placing ideology above patient care. He explains:

There is excess capacity in the private health system. There is also an ability in the private health system to provide even more excess capacity at relatively short notice. Most surgical clinics have been constructed to allow rapid expansion of wards and theatres, particularly if resource consents are streamlined.

There are thousands of people on elective surgical waiting lists who are waiting many months to years for operations. Most of them could have already had their operations if the private sector was allowed to properly partner with DHBs. Currently, most private sector “public” operations are done under limited contract – often 1 or 2 surgical sessions at a time. There is absolutely no incentive for the private hospital system to “flex up” as the huge demand is being dealt with in a piecemeal fashion.

This is bad enough for Mrs. Smith who has waited three years for her hip operation and can barely walk. It is life-threatening to those who need cardiac surgery or radiotherapy. I am certain that, if Saturday sees the return of a Labour government, the brand new radiotherapy clinic in Auckland will have a few patients sent to it by the DHBs – the ones who have waited well beyond a safe waiting time. There will, however, be no concerted plan negotiated between the DHBs and the new clinic to maximise this new resource, because Mr. Cunliffe is apparently nearly out of his comfort zone.

This means, to put it baldly, people will die because of his ideology.

He also dispels the myths around using the private sector more:

I hear objections to using private health care occasionally from my colleagues. Their objection is that, if you move these patients out of the public system, hospital doctors will eventually have insufficient variety of work to maintain their skill sets (”I’m in charge” Cunliffe puts it as “sucking capacity out of the public system – a nonsense phrase, if I have ever heard one). Apart from the dubious ethics of essentially denying people timely care in order to maintain a doctor’s skills (or non-existent theoretical hospital capacity), this objection does not hold water. Most of the surgery dealt with by the private clinics is low complexity. Private clinics usually lack ICU beds and so cannot deal with the very complex. What maintains your skills better – 10 routine hip replacements or three complex revisions? Removing a dozen easy appendixes or a couple of complex appendix masses?

He concludes:

So let’s stop this whining about privatising medicine and use all of our resources, both private and public, to get the medical care that people need. National’s thoughts on this are very promising, particularly the multiyear funding guarantee which will enable both public and private resources to expand capacity with confidence. Yet another reason to vote for the three-headed hydra.

I note that the Herald uses the word “Elite” meaning “private”. I realise this is probably due to space constraints in their headline, but it is hugely insulting to those people who are having to mortgage or sell their homes in order to get the surgery they desperately need. I think we need to get past the place where we see private medicine as the domain of the wealthy and see it as a normal and valuable part of the entire health system.

This should be an op ed in a newspaper.

National has pledged to fund 20 new elective surgery theatres and train 800 additional surgeons, anaesthetists and nurses to staff them.

And what is Labour’s response:

Minister of Health David Cunliffe said the National plan was an “unworkable imitation of current Labour Party policy” and questioned where National would find the additional medical staff given the shortages.

The only way to build 20 theatres would be through privatisation, he said.

This sums up everything wrong with Labour. They would rather have 20 less operating theatres, than have the private sector involved. Their concern is not the health needs of New Zealanders, but their anti private sector ideology.

And I won’t even try and comprehend how you privatise an operating theatre that currently doesn’t even exist!

In the 1999/2000 years $6.8 billion was spent on Vote Health. In 2008/2009 Vote Health was forecast to be $12.6 billion. Now some of this is to over inflation and population growth but it is still a huge amount of extra funding. And what has been the result?

The Press editorial notes:

Heart disease is a leading cause of death in New Zealand and there have been longstanding concerns about the level of cardiac surgery services, writes The Press in an editorial. Yesterday’s report into cardiac surgery confirmed that these concerns were justified. The report found that this nation lagged behind comparable nations in heart surgery rates, with Australia’s level of service being 85 per cent higher and that within New Zealand there were significant regional variations.

Australia’s level of service is 85% higher.

And not only is this an election year when the Government must defend its health record, but another critical report, issued by the Ministry of Health yesterday, said that eight patients who died in 2006 and 2007 while awaiting heart surgery at Wellington Hospital had avoidable delays in their treatment.

Eight actual avoidable deaths, as oppossed to Helen’s invented 60 deaths in Iraq.

It is worth noting that a total of 16 people died while waiting for cardiac surgery during those two years, so that figure of eight being preventable represents half of them.

National has pledged to lift the number of annual places in medical school from 365 to 565, over five years. This would be the biggest increase ever.

We are currently one of the biggest importer of doctors in the world, and producing more doctors locally is sensible. And the student loan abatement for staying in NZ, along with lower taxes, should help keep them here.

MacDoctor proposes an alternative billboard for National

National has released a policy to incentivise doctors, nurses and midwives to stay in New Zealand, and even No Right Turn likes it.

Policy details are:

• Voluntary bonding with student loan debt writeoffs
• Will apply to those willing to work for three to five years in hard to staff communities or specialities
• A maximum annual write off of $10,000 per annum
• $30,000 written off (if at maximum rates) after year three and then $10,000 a year for the next two years if they stay on.
• Will apply to anyone who graduated from 2005 onwards
• Will be extended to other health professionals over time
• Cost is initially $3 million in year one expanding to $9 million in year three which covers 100 doctors and 250 nurses and midwives.